HomeMy WebLinkAbout4308 Nicholas Rd - Engineering
^"....~ 0 0 44 5
\S ~~~;~T~_~~~S=~N PERMIT
~ City Phone: 206-457-0411, ex!. 124
.....t'UCANT/OWNER: [) S W QST~Y'<>'" . AD~RESS OF JOB: 4 ~o3 N 1~{L'.'j 2e5l
APPUCANT ADDRESS: PHONE LEGAL OF JOB:
WORK IS 0 OUTSIDE or 0 INSIDE OF TRAVELED ROAD VALUE OF WORK IS:$ (If work is outside roadway
and is equal to or I.... than $2,000, lben permit may be issued to olber than licensed and bonded contraclor.)
PLANS REQUIRED 0 YES [] NO CONTRACTOR: DATES FOR START & FINISH
PERFORMANCE BOND REQUIRED [] YES 0 NO AMOUNT: $
PROOF OF INSURANCE:[] Worle $2,000 or I...: $50,000 personal injwy, $100,000 per incident, $20.000 property
o Worle over $2,000: $200,000 penonal injury, $500,000 per incident, $100,000 propeny
o Right of Way Use: $300,000 pcnonal injury, $300,000 per incident, $100,000 propeny
Pmliillec undcntaadI that no atrcet may be eloecd to traffic unJ_ approved by lbe City Ensin- and Cbief of Police in advmcc of lbe
closure: that lbcrc is a 24 bour m;n;mnm notice prior to inspection, and to call 48 hours before digging to: 1-800-424-5555,
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DATE: S12 ~!,q &;
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""" FEE 'AID TYPE FEE 'AID
lJQHTO,WAYEXCAV. ..... ~EWEa un.1 C6" 1O,n.., "&4' ...... I
.....<D. SAN. - ...~-~. ht_ ......
......mn SI25m SAN SEWn tUn' . "DO. UNrr U.<D
Dl/YEWAT 112S.oa IAN lEWD. OTHD.J . ....-I1S_ ~.0115u_
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~~~ ..... JEWEl TAP. IY CITY tfO 112S..lll)'S.)CIUD
rnEEI' cur. ...... DlO.ClO SEWEa CM"'ATEI WETD. =...
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0T1ID. lJOKf 0' w.\ y wax ..... ALTD.ATIOHI .13D.<D
UPAlJ. TO SEWn.
mJ!1lYtlOAI<1' DI'J'OSIT STO.'" OKAD'l T A' 1113.00
us. 'NATO nKYIC'I! I- X ""- ""'.<D CATCH BASINS IH LOTS PO EACH ....'"
us. "'ATO SDVIC!: I- X )I.- lm.<D SECONOMY SEWEll ASSESS. "'10.00 ... "".00__"'" !
LE!. WATn 'y,' -~ '~'Y'. O' t]1Hx)/NfU I
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COWM. WATU ID.VICE I- -1I,em Wa..WAUK.EE DR. IEWEl .usDS. '''Dm I[WW
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WATDSD.VJC1E.OTHI!I. EmMA'" .JOKTOFWAY USEPD.Mm YUlES SJ. 1100
W'ATEI. J'YS. DEV. CHAlOI mo.<D....... TOTALS I I II
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COMMENTSICONDmONS:
[J lnala.ll C Repair
CWalermIin
[J Saitary Sewer
[J SlOnD Drain
[J UIIIlaground ToIcpboDeIElcctrical
.JWIT TOTALS $
RECEIPT
#
. 3-0-
ISSUED BY: \ *-/~ .
DATE:cS~ ::
PW-0209.03 (121931
INSP!!CJ'OR'S COPY . WHrrE APPLlCANI'"S copy. PINK
WORK ORDER No,
00445
ornCE COPY . CANARY PERMIT
INSPECTION FEES $
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WORK lUl;ATlO"1
Addruss ~Z O~
Cit.,fl,... 1-.
Nllmu
Subdivision
CusI. Signature (Optional)
Customer may ref r Queslions 10: 800-737- 0477
Submitted by: W1?11 OCB'*-fPauer ?o2~/2.J.i,
Cel! 4-W~1161
lNSTAlLA T10NIAEPAIR
New a CF a 50#
Rearrange CJ Add Une a
Repair)( 005 X TN" .360--467;164-8'
TTN# ' .2I2$.t:. 2.!? K
CJ CBR# .3t.o-457-lfS'K L
.J:!K YON 8e-vt TltOMtlS
OJ. /1 .4 ,,,,,- -fr,.. It e.f~ t; 0 I.-<.-
PRE.PROVISIONING I,,~ -k!ep~e d7~s
Pre Bury a ~ w~ /;" e...
Conduit Placed Partial a Complete CJ
BSW in Open Tr. Partial a Complete a
Extend SSW on partial conduit or Open trench CJ
Home Ready for SNIIGND 0 Not RtJBdy a
r;; --203 (I
BURfED SERVICE WIRE #:
WORK ORDER DA TE : ,5' //. 3 ~
CONTRACTOR'S ACCEPTANCE
Firm
Signature
Title
USWest group doing work
Bill to: USWest Communications
Attention:
Address:
City:
Zip:
--~
D~te;
FOU"d T e "'p
Temporized?
Recommended:
Approved by:
Date:
-
Date:
c/4'~~ -
PERMIT Rr;ol!'R~D?/. ~ Ye"s L CI No
,.v~t2,J -fe(t'~e t- IVA-k< mcde,
Received from Verbal 0
Jurisdiction No. Date: I;'
~
8~
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D'"e: r-
for service connectiO;:;--~
/ COMPLETEO BY:
l-ALLK..JtL T Lf_) Call
( Add $ to right if sketCh sent to con~ractor l n ;/-
Ca.,e,( BB-v1. r/'-I!"" tt.S -fc9 /, -€ f/> yo IA._-ift'?
Is there additional Customer billing? Cl Yes .3"~
Does TeCh need notified? a Yes a;, No
MAPt/
CSl
COLOR/Bp
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Sketch WOrk Required . Include nearest Cross street
and wIre length
llae fot'ltl RO .c 1-G087.1 if Addit;orullpacf II ~
ItldJeate North
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Nolo: This sk"ch may not ". on Oecorol. ,opt...ntolon In all details. ~ temoins the con'OIclor'. t..ponsibjUly 10 properly loc". ....rk in lie/d,
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H~MOl NVld 0998 Zgr NOH~ Wd LE:EO 96-EI-90